Continuing Education Activity

Muscle energy is a versatile and effective option for treating somatic dysfunctions. These techniques can be direct or indirect and passive or active. This activity describes the treatment of exhaled ribs and explains the health care team's role in treating exhaled ribs.

Objectives:

• Identify indications and contraindications of muscle energy.
• Summarize the steps of the muscle energy procedure for exhaled ribs.
• Describe the anatomy of an exhalation dysfunction.
• Describe how an interprofessional team can coordinate their care to perform the exhaled rib technique and technique and improve patient outcomes.

Introduction

This article aims to explain the procedure for treating exhaled ribs using the muscle energy Osteopathic Manipulative Treatment (OMT) method. For example, OMT can be used with various techniques, including high velocity/low amplitude, muscle energy, strain-counterstrain, and myofascial release.[1]  

These techniques can be direct or indirect and passive or active. A direct technique is when the restrictive barrier is engaged, while indirect techniques occur when forces are applied away from the restrictive barrier. Passive techniques are ones in which the operator does the work, and the patient is in a relaxed position, and an active technique is one in which the patient is helping with the treatment.[2]  

Muscle energy is a direct and active technique such that the patient is placed into their restrictive barrier and participates in their own treatment. When the patient is placed into their restrictive barrier, they participate by actively moving towards their neutral position. During this time, the physician holds an isometric counterforce.[3]

Rib dysfunctions can cause multiple symptoms, including musculoskeletal or chest pain, thoracic outlet syndrome, difficulty in taking a full breath, and overall worsening of respiratory pathology.[4] The diagnosis and management of rib dysfunction may also benefit patients with respiratory disorders such as asthma, chronic obstructive pulmonary disease (COPD), and pneumonia. Adequate respiration requires normal movement of the diaphragm, ribs, and sternum, which increases and decreases the size of the thorax, generating positive and negative pressure required for proper respiration and oxygen exchange.[5] 

Exhaled rib dysfunctions specifically occur when two or more ribs are displaced or stuck “down” or caudad. This means that the rib is restricted during inhalation and cannot move up, preventing the ribs from moving during inhalation. In this case, the top-most rib within the group of ≥ 2 adjacent ribs is targeted for treatment.[6]

Anatomy and Physiology

There are twelve sets of ribs in the human body. Anteriorly, these are attached to either the sternum, costal cartilage of adjacent ribs, or no anterior attachment. Posteriorly, the twelve sets of ribs are attached to the spine at the costovertebral articulations.[7] The ribs are further broken down into true ribs, false ribs, and floating ribs. Ribs 1 through 7 are considered true ribs as they attach anteriorly to the sternum. Ribs 8 to 10 are known as false ribs as they attach to the cartilage of ribs 1-7 and not directly to the sternum, and ribs 11 to 12 are considered floating ribs are they do not have an anterior attachment.[7]

The motion of the ribs also varies slightly based upon their attachment. The first five ribs are considered pump-handle and move in an anterior-posterior motion, increasing during inhalation and decreasing during exhalation. Ribs 5 to 10 are considered bucket-handle ribs and move transversely with increased diameter during inhalation and decreased diameter during exhalation. Finally, ribs 11 to 12 are considered caliper or pincer-type ribs and move in a down and out motion during inhalation and up and in during exhalation.[8] 

Ribs are connected to specific muscle groups, which are essentially the target for muscle energy. Each rib or set of ribs moves into inhalation vs. exhalation based on the contraction of specific muscles or muscle groups. The origin of the anterior and middle scalene is on the cervical vertebrae (CII-CVII), while the insertion is to the first rib. The posterior scalene inserts at Rib 2. The pectoralis minor muscle originates on ribs 3 to 5 near the costochondral junction and inserts at the medial border and superior surface of the coracoid process of the scapula. The serratus anterior originates at ribs 6 to 9 and inserts at the costal aspect of the medial margin of the scapula. Finally, part of the origin of the latissimus dorsi is from ribs 10 to 12, while the insertion is at the intertubercular groove of the humerus.[9][10]

Indications

Muscle energy of the ribs has many indications. This technique can be used in elderly or acutely ill patients without contraindications. It can also be used in chronic conditions such as COPD, asthma, or interstitial lung disease. Data shows that osteopathic manipulative treatments such as muscle energy can be beneficial in post-surgical or ICU patients.[11] Finally, any individual with somatic dysfunction can benefit from this technique, including those who use it as a way of stretching and opening up their chest for optimal physiological movement.

Contraindications

Contraindications for a technique such as muscle energy include patients who are unable to actively participate in the treatment or are unwilling to do so. Rib fractures, recent spinal injury, or known ligament laxity is another contraindication to this technique. Finally, active infection of the skin or underlying muscle is another contraindication, as is metastatic cancer, which could potentially spread due to muscle energy to the ribs.[12]

Equipment

The muscle energy technique requires a patient to be sitting upright or lying supine and be able to participate in the treatment. A patient, a trained provider, and a cushioned manipulation table are needed to complete this technique.

Personnel

A trained practitioner and a patient who is willing and able to undergo treatment are the required personnel for this treatment. 

Preparation

To complete this technique, verbal and/or written consent are required. In addition to consent, an understanding of the procedure and hand placements should be explained, along with the reason for completing the technique and any available alternate techniques. Finally, the patient is required to be willing to undergo the technique.

Technique or Treatment

For muscle energy ribs 1 to 2, the patient is positioned supine, and the provider stands at the head of the table. Provider grasps affected rib angle underneath the patient and places the dorsal aspect of the patient’s ipsilateral wrist onto their forehead while it is turned 40 degrees away from the side of dysfunction. While the patient inhales, apply inferolateral traction to the rib angle. Ask the patient to hold their breath for 3 to 5 seconds while lifting their head up towards the ceiling, as the provider administers equal resistance. Then ask the patient to relax for 5 seconds. Engage the rib barrier and repeat above mentioned steps until a desirable outcome is achieved.

For muscle energy ribs 3 to 5, the patient is positioned supine, and the provider stands contralateral to affected ribs. Provider grasps affected rib angle underneath the patient and abducts the patient’s ipsilateral shoulder. While the patient inhales, apply inferolateral traction to the rib angle. Ask the patient to hold their breath for 3 to 5 seconds while bringing their elbow upwards as the provider administers equal resistance. Then ask the patient to relax for 5 seconds. Engage the rib barrier and repeat above mentioned steps until a desirable outcome is achieved.

For muscle energy ribs 6 to 9, the patient is positioned supine, and the provider stands contralateral to the affected ribs. Provider grasps affected rib angle underneath the patient and abducts the patient’s ipsilateral shoulder and elbow to 90 degrees with their wrist facing upwards. While the patient inhales, apply inferolateral traction to the rib angle. Ask the patient to hold their breath for 3 to 5 seconds while pushing their arm anteriorly as the provider administers equal resistance. Then ask the patient to relax for 5 seconds. Engage the rib barrier and repeat above mentioned steps until a desirable outcome is achieved.

For muscle energy ribs 10 to 12, the patient is positioned supine, and the provider stands contralateral to affected ribs. Provider grasps affected rib angle underneath the patient and abducts the patient’s ipsilateral shoulder to 180 degrees. While the patient inhales, apply inferolateral traction to the rib angle. Ask the patient to hold their breath for 3 to 5 seconds while adducting their elbow as the provider administers equal resistance. Then ask the patient to relax for 5 seconds. Engage the rib barrier and repeat above mentioned steps until a desirable outcome is achieved.[12]

Complications

Patients should be warned that muscle and joint soreness are possible after manipulation. If a patient frequently experiences muscle soreness after manipulation, they can be instructed to take an over-the-counter pain reliever before the manipulation. While rare, serious complications can occur.[13]  

Clinical Significance

Unfortunately, there are few studies that investigate the efficacy of muscle energy, and a systematic review of randomized control trials from multiple disciplines that practice physical manipulations for muscle energy in patients with COPD was inconclusive.[14][15] However, while not specifically regarding muscle energy, the American College of Physicians recommend strongly that manipulation, among other therapies, be attempted as a first-line measure for acute and chronic back pain.[16]

One of the best-known and used osteopathic medicine (OMT) approaches is the Muscle Energy Technique (MET).[17] The MET was conceived by Fred Mitchell senior about half a century ago; the objectives of this approach are to improve muscle function, restore physiological length to a shortened contractile district, improve joint movement and reduce any inflammatory symptoms.[18]

The effectiveness of the technique will depend on some factors, such as the correct positioning of the joint and the correct muscle tension, an exact diagnostic path, a force put by the operator sufficient to change the muscular behavior of the area, and an adequate repositioning of the articulation after the manual procedure.[18] MET is also indicated in cases of muscle stiffness, for example, after thoracic surgery, and to counteract the presence of trigger points.

The clinical mechanisms that explain the positive response to the technique are not fully understood. MET could stimulate mechanoreceptors and send muscular-articular afferents to inhibit nociceptive afferents, as in a reflex circuit, by varying the mechanical and metabolic environment of the treated area. The technique could stimulate reciprocal inhibition, making the activated muscles more relaxed and stretch, with gain in joint movement. Another hypothesis is improving fluid drainage, improving the metabolic environment, and lowering inflammatory indices and nociceptive substances.[18]

When to choose to perform a MET? This technique has no side effects. The concept of this approach is to exploit the force that the patient can express, respecting the physiological limits without creating pain or discomfort. The technique can also be used to prepare other techniques, such as a high-velocity low-amplitude (HVLA) or for more demanding stretches, and prepare the ribs for more effective work on the diaphragm muscle. For example, after a sternotomy cardiac surgery, patients may present positional changes in the rib joints, causing pain. To improve the function of the respiratory muscles and the muscles that affect the rib cage, respecting the sternal wound, it is possible to perform a MET. When the pain has improved, other more comprehensive approaches (such as unwinding or more challenging rehabilitation exercises) can be performed, increasing the patient's ability to breathe and move. The presence of a scar due to previous trauma or surgery can alter the movement of a rib and the surrounding muscles. In this case, it is necessary to know that MET can be used to increase the range of motion (ROM) of the rib, improving the afferent/efferent picture of the treated area but, precisely because of the scar presence, it is likely that the reduction of the ROM can to return. In this situation, it is not wrong to reschedule visits for the patient and periodically carry out this manual technique, to obtain more lasting maintenance of muscle and joint movement.

To conclude, MET can be used as the only technique if the result is the complete restoration of joint and muscle function, or the technique can be used to prepare for more demanding techniques for the patient.

Enhancing Healthcare Team Outcomes

The key to treating any disease is identifying an illness or dysfunction, investigating appropriate treatment strategies, and ensuring that the patient is willing and eligible for any specific treatment. In terms of muscle energy of exhales ribs, coordinated patient care is essential to ensure that the patient is being treated for the correct dysfunction. A coordinated approach with the patient’s primary care physician and an emergency room physician, for example, can help extrapolate the root cause of chest pain being cardiac or musculoskeletal in nature. An appropriate referral can then be made to ensure accurate diagnosis and treatment.

Following treatment, it is essential for the whole healthcare team to take care of the patient, including nurses, home health aides, primary care clinicians, and the treating provider, to formulate an appropriate treatment plan and reduce pain. A pharmacist can also be involved if the patient requires pain medications to monitor an increase or reduction in the number of drugs used in combination with Osteopathic Manipulative Treatment. It is also essential for the interprofessional healthcare team to ensure that none of the contraindications mentioned above applies to a patient. Such methods would ensure a well-rounded systematic approach to treating patients with underlying musculoskeletal complaints while ruling out other disease processes.